0:09Skip to 0 minutes and 9 secondsIn the last step, Michael Borg talked about power distance and uncertainty avoidance, and why they're important to antimicrobial stewardship. What this slide shows is data from the Cochrane Review update. So this is a review of interventions to improve antibiotic prescribing in hospital inpatients. The update has literature that was published up until the end of 2014 and is about to be published in the Cochrane Library. So there are 223 interventions in the review. They come from 35 countries. And what we've done on this slide is to plot out the power distance index and the uncertainty avoidance index for those 35 countries. So you can see, the countries fall into one of four quadrants.

1:06Skip to 1 minute and 6 secondsMost of the studies, 150 of them, or 67% percent of the total, come from countries that have both weak uncertainty avoidance and small power distance. On the opposite bottom right hand corner of the slide, you've got studies that have strong power distance and strong uncertainty avoidance. And I think we might be concerned that so much of the evidence of our interventions comes from countries in the top left hand corner. However, we have deliberately picked for you studies that are in the bottom right hand corner. So the study by Weinberg, which you've already looked at in detail, came from Columbia and another study that we're going to look at which is a successful intervention, again, about antibiotic prophylaxis comes from Taiwan.

1:58Skip to 1 minute and 58 secondsSo both of these studies show that the model for improvement and the approach to behaviour change that we're suggesting you take will work in these countries. And as Michael Borg said, it's not that these are insurmountable barriers to change, you just have to be aware of how your hospital might be slightly different from the hospital where the intervention, successful intervention was done, and understand how you can adapt the intervention to take account of that. This chart shows the results of an intervention in a hospital in Taiwan. The intervention was about antibiotic prophylaxis for cardiac surgery and the behaviours that they wanted to change were the same ones that you were asked to consider in the previous step.

2:55Skip to 2 minutes and 55 secondsSo what they want to do is increase the number of patients who had prophylaxis and had a first dose within one hour of incision but they also wanted to reduce the length of prophylaxis. So they were trying to increase the proportion of patients who had prophylaxis discontinued within 24 hours. As you can see from the chart they had a significant impact on both of these prescribing outcomes. In the paper, they explain how they designed the intervention and although they don't talk about power distance, they were clearly aware that they really, in Taiwan, it was going to be very important to involve senior cardiac surgeons in endorsing what they were doing.

3:44Skip to 3 minutes and 44 secondsSo they actually identified the key cardiac surgeon in Taiwan and invited that person to attend their meetings, and to endorse what they were doing. And they had a regional symposium on surgical prophylaxis, where again, this key cardiac surgeon guaranteed his attendance at the meeting, and along with nationally well-known experts in surgical infection, gave talks about the intervention. So right from the start, they had their senior endorsement that was going to be particularly important to them. Congratulations on successfully completing week five. We've considered the barriers to behaviour change and how they can be overcome. I'd like you to take away two clear messages from this week. The first one is we need better design and reporting.

4:39Skip to 4 minutes and 39 secondsAnd we've shown you how to use the model for improvement to design and report your interventions. The second take home message is that we need more diversity, in terms of the countries that are contributing literature about interventions to change antibiotic prescribing. In week six, you're going to hear about how successful interventions have been achieved in both South Africa and India. So that's adding further to the information we've already started to discuss about how interventions can be adapted in countries that have more power distance hierarchies and more uncertainty avoidance barriers, and also have problems with the relatively poor resources. So overall, I think we're showing you how you can do interventions, how you can report them.

5:36Skip to 5 minutes and 36 secondsAnd we believe that you can do this. And we would really like countries who are not currently represented in the Cochrane Review to come forward and apply the simple model for improvement and show us what you've done.

The Cochrane Review and closing comments

Within Europe cultural models have explained between 25% and 50% of variance in infection-control processes and outcomes.

It is likely that specific combinations of cultural dimensions are more amenable to adherence to antibiotic policies than others. However, acknowledging the role of culture should not be used as an excuse for inaction, rather it should enable interventions to be better designed for specific cultural contexts.

Watch this final video in which Professor Peter Davey explains the findings of the Cochrane Review into interventions to improve antibiotic prescribing and the cultures in which these have taken place.

So we are at the end of Week 5 with one more week to go.

Resources

All of the resources for this week and subsequent weeks have been logged on the BSAC resource platform, ARC.